DEPARTMENT OF CHILDREN AND FAMILY SERVICES
YOUTH DEVELOPMENT SERVICES DIVISION
REQUEST FOR INDEPENDENT LIVING PROGRAM (ILP) SERVICES
Rev. 7.15.2019
Request Date: ____________________________
Dear Transition (ILP) Coordinator: __________________________________
I am ______________________________ requesting assistance from ILP for the following
(Print Name)
Graduation Expenses Dorm or Apartment Start-Up Expenses**
Tuition Rent **
Books & Supplies* Rent Deposit Reimbursement **
School Clothes** School or Exam Fees Reimbursement
Transportation (pass, tokens or airfare) Other ______________________________________
Work Clothes
*Funds are restricted to high school, college or vocational students
**Funds are restricted to ILP eligible youth that have exited the foster care system
Reason for Request: __________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Attached documents verify need:
Pay Stubs School Enrollment Documents
Financial Aid Award Letter Letter from Counselor
Cost Estimate Original Receipts
Lease/Rent Agreement Other: _______________________
(original signatures)
Thank you,
__________________________________ _________________________________
(Signature) (Print name)
Address: ___________________________________________________________ Apt # ______
City: __________________________ State: ______ Zip Code: ________________
Mailing Address (where you would like the check mailed):
____________________________________________________________________ Apt # _______
City: __________________________ State: _________ Zip Code: ______________
Phone Number: ______________________ Email address: __________________________________
Last 4 Digits of Your Social Security No: __________________ Date Of Birth: __________________
Student ID# (if applicable):______________________
Name and phone # of CSW/DPO (if applicable): ________________________________________
Note: You must provide the required documentation necessary for your request to be processed. A request cannot be processed if there is no
funding available or your request is incomplete. This is only a request for services and in and of itself is not a promise or guarantee that services
or funds will be granted.
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